Nursing Assessment / process and Importance

1. Health Assessment
FACULTY : TARIQ JAVED GILL

2. WHAT IS HEALTH ?
•A state of complete physical, mental and
social well-being, not merely the absence
of disease or infirmity” (WHO, 1947)
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3. The Health Triangle
THREE ASPECTS OF
HEALTH

4. THREE ASPECTS OF HEALTH
Health is the measure of our
body’s efficiency and over-all
well-being.
The health triangle is a measure of
the different aspects of health.
The health triangle consists of:
Physical, Social, and Mental
Health.
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5. NURSING PROCESS
The Cornerstone of The Nursing Profession
•The nursing process generally is defined as a systematic problem-
solving approach toward giving individualized nursing care.
•OR
The nursing process is a systematic method that directs the nurse
and patient as together they accomplish the following:
(1) Assess the patient to determine the need for nursing care; (2)
determine nursing diagnoses for actual and potential health
problems; (3) identify expected outcomes and plan care; (4)
implement the care; and (5) evaluate the results. 5

6. 6

7. Nursing Assessment
• The first phase of the nursing process, called
assessment, is the collection of data for nursing
purposes. Information is collected using the skills of
observation, interviewing, physical examination,
and intuition and from many sources, including
clients, their family members or significant others,
health records, other health team members.
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8. Objectives of health assessment
 Surveillance of health status, identification of occult disease,
screening, and follow-up care.
 The periodic assessment, at regular intervals.
 Increasing client participation in health care.
 Accurately define the health and risk, care needs for
individuals.
 Health assessment is shared with the client in a clearly and
understandable manner.
 The client must share in decision making for his own care.
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9. Reasons for doing assessment:-
- To establish baseline information on the client
- To determine the client’s normal function
- To determine the client’s risk for dysfunction
- To determine the client’s strengths
- To provide data for the diagnosis phase
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10. Reasons for doing assessment:-
• To confirm or refuse data obtained in the health
history.
• To identify nursing diagnoses.
• To make clinical judgments about client's changing
health status.
• To evaluate bio-psycho-social & spiritual outcomes
of care.
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11. Types of Assessment
•1- Initial assessment
•Aim: Initial identification of normal function, functional
status, and collection of data concerning actual or
potential dysfunction.
• Baseline for reference and future comparison.
•Time frame: Within the specified time frame after
admission to a hospital, nursing home, ambulatory
healthcare center.
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12. Types of Assessment
•2- Focus assessment
• Aim : Status determination of a specific
problem identified during previous
assessment.
• Time frame: Ongoing process, integrated
with nursing care, a few minutes to a few
hours between assessments.
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13. Types of Assessment
•3- Time – lapsed reassessment
• Aim : Comparison of client’s current status to
baseline obtained previously, detection of
changes in all functional health patterns after
an extended period of time has passed
• Time frame : Several months (3,6,9 months or
more) between assessment
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14. Types of Assessment
•4- Emergency assessment
• Aim : Identification of life – threatening
situation
• Time frame : AT anytime
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15. Setting and environment
•
Assessment can take place in any setting where
nurses care for clients and their family
members: in the client’s home, at a clinic, in a
hospital room.
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16. Assessment skills
1- Observation
Comprises more than the nurse’s ability to see the client,
nurses also use the senses of smell, hearing, touch, and,
rarely, the sense of taste. Observation includes looking,
watching, examining. Observation begins the moment
the nurse meets the client. It is a conscious, deliberate
skill that is developed through efforts and with an
organized approach. Observation has two aspects: (a)
noticing the data and (b) selecting, organizing, and
interpreting the data.
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17. Assessment skills
•2- Interviewing
Is a planned communication or a conversation
with a purpose, for example to get or give
information, identify problems of mutual
concern, evaluate change, teach, provide
support. There are two approaches to
interviewing, directive and nondirective.
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18. Assessment skills
• The directive interview is highly structured and
elicits specific information. The nurse establishes the
purpose of the interview and controls the interview.
The client responds to questions but may have
limited opportunities to ask questions or discuss
concerns. The nondirective interview or rapport-
building interview, by contrast the nurse allows the
client to control the purpose, subject matter, and
pacing.
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19. Assessment skills
•3- Physical examination techniques
Is a systematic data collection method that uses
the senses of sight, hearing, smell, and touch to
detect health problems. Four techniques are
used: inspection, palpation, percussion, and
auscultation.
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20. Assessment skills
• Inspection
Is visual examination of the client
that is done in a methodical and deliberate
manner. The client is observed first from a
general point of view and then with specific
attention to detail. Effective inspection requires
adequate lighting and exposure of the body
parts being observed.
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21. Assessment skills
•Auscultation
Involves listening to sounds in the body that
are created by movement of air or fluid. Areas
most often auscultated include the lungs, heart,
abdomen, and blood vessels.
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22. Assessment skills
•Palpation
Uses the sense of touch to assess texture,
temperature, moisture, organ location and size,
vibrations and pulsations, swelling, masses,
and tenderness. Palpation requires a calm,
gentle approach and is used systematically,
with light palpation preceding deep palpation
and palpation of tender areas performed last.
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23. Assessment skills
•Percussion
Uses short, tapping strokes on the surface of
the skin to create vibrations of underlying
organs. It is used for assessing the density of
structures or determining the location and the
size of organs in the body.
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24. Assessment skills
•4- Intuition
Use of insight, instinct, and clinical experience
to make clinical judgments about the client.
Intuition plays a role in the nurse’s ability to
analyze cues rapidly, make clinical decisions,
and implement nursing actions even though
assessment data may be incomplete or
ambiguous.
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25. Assessment skills - Assessment Activities
•
The activities that make up the assessment are
the following:
1- Collect data
Data collection, the process of compiling
information about the client, begins with the
first client contact. Nurses use observation,
interviewing, and physical examination.
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26. Types of data:
•
-Subjective data also known as symptoms or
covert cues include the client's feeling and
statement about his or her health problems and
are best recorded as direct quotations from the
client, such as
'' Every time I move, I feel nauseated.''
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27. Types of data:
•- Objective data also known as signs or
overt cues, are observable and measurable
(quantitative) data that are obtained
through observation, standard assessment
techniques performed during the physical
examination, and laboratory and diagnostic
testing.
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28. Sources of data
It can be primary or secondary. The client is the
primary source of data. Family members or
other support persons, other health
professionals, records and reports, laboratory
and diagnostic analyses, and relevant
literatures are secondary or indirect sources.
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29. Assessment Activities
2- Validate data
Validation, commonly referred to as double –
checking the information at hand, is the
process of confirming the accuracy of
assessment data collected. Validation assists in
verifying and clarifying cues and inference.
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30. Assessment Activities
• 3- Organize data
After data collection is completed and information
is validated, the nurse organizes, or clusters, the
information together in order to identify areas of
strengths and weaknesses. This process is known as
data clustering. How data are organized depends
on the assessment model used. One of these model
is Head – to – Toe model.
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31. Assessment Activities
•4- Documenting Data
To complete the assessment phase, the nurse
records client data. Accurate documentation is
essential and should include all data collected
about the client’s health status. To increase
accuracy, the nurse records subjective data in the
client’s own words to avoid the chance of
changing the original meaning.
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32. Importance of health assessment
1. Systematic and continuous collection of client data.
2. It focus on client responses to health problems.
3. The nurse carefully examine the client’s body parts to
determine any abnormalities.
4. The nurse relies on data from different sources which
can indicate significant clinical problems.
5. Health assessment provides a base line used to plan
the clients care
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33. Importance of health assessment
6. Health assessment helps the nurse to
diagnose client’s problem & the
intervention.
7. Complete health assessment involves a
more detailed review of client’s condition.
8. Health assessment influence the choice of
therapies & client's responses.
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